Expert Critique

Inflammatory bowel disease (IBD) in older patients is becoming more common due to aging of the IBD population in addition to the presence of newly diagnosed IBD in patients 60 years of age and older. This increase in older IBD patients is occurring worldwide and not just in the United States. The pathophysiology of IBD in the elderly is thought to be more likely due to changes in the gut microbiome and impaired regulation of the immune system and less likely to genetic predisposition, which plays a role in IBD onset at younger ages.

IBD in elderly patients presents several challenges. Older patients may not present with typical IBD symptoms, making the diagnosis of IBD more difficult. Older patients tend to have more comorbidities, which limit the use of certain IBD medications for treatment. In addition, older patients, who are already at a higher risk for infections, are more likely to have an adverse event with some IBD medications, such as infections or intolerable medication side effects. Long-term steroid use is perceived as being safer in this population, but steroids are also associated with significant adverse events including infections and impaired bone health.

Treatment goals for older IBD patients need to be determined on an individual basis including the selection of treatment and the goals of treatment. For some patients, achieving mucosal healing may be important; for others, however, improving symptoms and quality of life may be the most important treatment goal. For older IBD patients, as with all IBD patients, it is important to continue to monitor for flares of their IBD and ensure that patients are up to date with preventive care measures, particularly vaccinations.

Full Critique

Managing inflammatory bowel disease (IBD) in older patients presents distinct clinical challenges, including assessing the safety, tolerability, and response to steroids, immunomodulators, tumor necrosis factor alpha (TNFα), and integrin antagonists, as well as the risks of surgery and the cost burden on the healthcare system.

And those challenges can only increase as the number of older people with IBD rises incrementally with the senescence of the population, Seymour Katz, MD, director of Inflammatory Bowel Diseases Outreach Programs at NYU Langone Medical Center in New York City, told MedPage Today. Today, an estimated 10-15% of IBD sufferers in the United States are age 60 or older -- and in Asia, studies show that 15% of IBD patients are over age 65.

"Within that older group, about 20-30% would be newly diagnosed at age 60 or older," Ashwin Ananthakrishnan, MBBS, MPH, of Massachusetts General Hospital in Boston, said in an interview.

In this country, as around the world, increasing ethnic diversity is changing the face of IBD, with patients of Korean, Chinese, Indian, and Latino background, Katz said. "We use to think of IBD as a Jewish disease affecting people who lived in Manhattan by the park, near Mount Sinai Hospital."

Also shifting, he said, is the profile of the elderly IBD patient in particular: "We used to think it was primarily ulcerative colitis affecting this population, but now [the cases are] mimicking the younger population and we're seeing more Crohn's. Elderly ulcerative colitis patients have higher rates of surgery and mortality, and while they have higher mortality in Crohn's, surgical rates are comparable to those in young patients. That's been a big shock to us, since we always thought it was younger patients who had more surgery."

The higher morality in the elderly is more often due to cardiac, pulmonary, and other comorbidities than to IBD, he added.

On the genetic front, genes play less of a role in the pathogenesis of older-onset IBD, while dysbiosis and immune dysregulation are more significant.

Differential diagnosis may be difficult in older individuals as multiple other common diseases can mimic IBD symptoms. "You have to keep IBD on your diagnostic differential when someone presents with GI symptoms that are often due to other causes. You have to have a strong index of suspicion so there's no delay in diagnosis," Ananthakrishnan said.

In addition, the elderly are less likely to present with typical IBD symptoms of abdominal pain, diarrhea, and anemia and are more likely to have weight loss, bleeding, fever, and constipation. Older IBD patients are also less likely than younger patients to have a family history of IBD.

IBD's debilitating effects can augment age-related deficits in health and function, both cognitive and locomotor. "The problem is worsened by polypharmacy and drug interactions, as well as cognitive and physical decline, with some patients not being able to follow treatment instructions or even open pill bottles," Katz said.

And with aging comes immuno-senescence and greater vulnerability to infections and tumors, especially with immunosuppression. But the news is not all bad, said Katz: "We used to worry about using immune modulators because of the risk of lymphoma and skin tumors, but the biologics are turning out to be safer than we thought. We have very good recent data from the New York Crohn's & Colitis Organization that there is no increase in biologic-induced tumors in IBD patients taking anti-TNF therapy."

He was referring to a 2016 retrospective study by Jordan Axelrad et al reporting that in IBD patients with a history of cancer, exposure to an anti-TNF agent or an antimetabolite was not associated with an increased risk of incident cancer compared with patients who did not receive immunosuppression.

"But we have to start these agents early to prevent complications; we have to watch patients carefully and test even asymptomatic patients for C. difficile," Katz said.

Elderly patients have a lower rate of short-term clinical response to anti-TNF therapy than their younger counterparts do (but similar long-term outcomes) and a higher rate of severe adverse events such as serious infections with the same treatment, as Triana Lobatón et al reported in a 2015 retrospective study that included patients ages 65 and older.

Most experts agree on the need to accumulate more data on elderly IBD patients, a group not often included in clinical trials and for which practice patterns may be suboptimal. According to Ananthakrishnan, prolonged steroid use in the elderly is common, causing significant morbidity in infections and reduced bone health in this vulnerable population: "There tends to be overuse of corticosteroids and a reluctance to put older patients on immunosuppressive therapy, some of which is well founded because of other comorbidities and risks," he said.

But older patients should not be automatically excluded from trials and treatment with contemporary modalities. "There is a surprisingly positive response to newer therapies and surgery, provided that a distinction is made between fit-elderly and frail-elderly patients."

For this population, physicians also need to rethink the recent push for mucosal healing and better biopsies. "You have to start low and go slow in the elderly," Katz said. "Symptom relief trumps mucosal healing. You can't push drugs to such a degree that they have significant side effects. These patients can't tolerate the same treatments as people in their 40s do."

Dose escalation must be careful, and combination therapy may produce more side effects in this population, added Ananthakrishnan, also stressing the need to focus on functional rather than endoscopic results. "The daily impact of IBD can be greater for older patients. They may be housebound because of diarrhea and may need anti-diarrheal agents."

And beyond IBD therapy, it's crucial to ensure that the elderly take basic healthcare measures such as vaccinations against potentially fatal diseases such as flu and pneumonia, which are more likely to cause mortality than IBD.

"With an elderly person, the goal is to get them back to a reasonable pattern of living," Katz said. "To restore bowel function, improve quality of life, get them off steroids and out of hospital -- and keep them away from the surgeons."

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